1. Smoking Cessation Program Dr. Rasha Salama PhD Community Medicine Suez Canal University Egypt

2. Facts about Smoking • Most of those killed by tobacco are not particularly heavy smokers and most started as teenagers. • Approximately 50 percent of smokers die prematurely from their smoking, on average 14 years earlier than non-smokers. • Smoking kills one in two of those who continue to smoke past age 35. • There is evidence that smoking can cause about 40 different diseases. • the preventable mortality attributed to smoking is 8 percent of deaths in females and 19 percent in males. • Smoking is socioeconomically patterned with higher rates of smoking in lower socio-economic groups. Thus tobacco smoking produces a greater relative burden of disease and premature death in lower socioeconomic groups and is a major contributor to socioeconomic inequalities in health.

3. Facts (cont.) • Smoking, especially current smoking, is a crucial and extremely modifiable independent determinant of stroke. • Second-hand smoke (also called environmental tobacco smoke) is a Class A carcinogen and contains approximately 4,000 chemicals. • Exposure of children to second-hand smoke: • can cause middle ear effusion • increases the risk of croup, pneumonia and bronchiolitis by 60 percent in the first 18 months of life • increases the frequency and severity of asthma episodes • is a risk factor for induction of asthma in asymptomatic children.

4. Benefits of Smoking Cessation These points may be helpful in motivating people to quit smoking. Many smokers deny being at increased risk of cancer and heart disease and more accurate perception of risk may assist cessation efforts. • It is beneficial to stop smoking at any age. The earlier smoking is stopped, the greater the health gain. • Smoking cessation has major and immediate health benefits for smokers of all ages. Former smokers have fewer days of illness, fewer health complaints, and view themselves as healthier. • Within one dayof quitting, the chance of a heart attack decreases. • Within two daysof quitting, smell and taste are enhanced. • Within two weeks to three monthsof quitting, circulation improves and lung function increases by up to 30 percent.

5. Excess risk of heart disease is reduced by half after one year’s abstinence. The risk of a major coronary event reduces to the level of a never smoker within five years. In those with existing heart disease, cessation reduces the risk of recurrent infarction or death by half. • Former smokers live longer: after 10 to 15 years’ abstinence, the risk of dying almost returns to that of people who never smoked. Smoking cessation at all ages, including in older people, reduces risk of premature death. • Men who smoke are 17 times more likely than non-smokers to develop lung cancer. After 10 years’ abstinence, former smokers’ risk is only 30 to 50 percent that of continuing smokers, and continues to decline.

6. Women who stop smoking before or during the first trimester of pregnancy reduce risks to their baby to a level comparable to that of women who have never smoked. Around one in four low birth weight infants could be prevented by eliminating smoking during pregnancy. • The average weight gain of three kg and the adverse temporary psychological effects of quitting are far outweighed by the health benefits.

7. Evidence for Effectiveness of Health Professional Intervention • A Cochrane review of 16 RCTs found simple advice from doctors had a significant effect on cessation rates (OR for quitting 1.69; 95% confidence interval 1.45–1.98). • When trained providers are routinely prompted to intervene with people who smoke, they achieve significant reductions in smoking prevalence (up to 15 percent cessation rates compared with 5 to 10 percent in non-intervention sites). • Doctors and other health professionals using multiple types of intervention to deliver individualized advice on multiple occasions produce the best results. Frequent and consistent interventions over time are more important than the type of intervention.

8. Smoking Cessation Program • The only way any country can substantially reduce smoking and other tobacco use within its borders is to establish a well-funded and sustained comprehensive tobacco prevention program that employs a variety of effective approaches. • Nothing else will successfully compete against the addictive power of nicotine and the tobacco industry's aggressive marketing tactics.

9. ESSENTIAL COMPONENTS The following elements must all be included to maximize the success of any program to reduce tobacco use. Conducted in isolation, each of these elements can reduce tobacco use, but done together they have a much more powerful impact: • Public Education Efforts • Community-Based Programs • Helping Smokers Quit (Cessation) • School-Based Programs • Enforcement • Monitoring and Evaluation • Related Policy Efforts

10. Public Education Efforts: Research has demonstrated that tobacco industry marketing increases the number of kids who try smoking and become regular smokers. Not surprisingly, one of the best ways to reduce the power of tobacco marketing is an intense campaign to counter these pro-smoking messages.

11. Public Education Efforts (cont.): • These efforts must include multiple paid media (TV, radio, print, etc.), public relations, special events and promotions, and other efforts. • Counter-marketing efforts should target both youth and adults with prevention and cessation messages.

12. Community-Based Programs: • Because community involvement is essential to reducing tobacco use, a portion of the tobacco control funding should be provided to local government entities, community organizations, local businesses, and other community partners.

13. Community-Based Programs (cont.): • These groups can effectively engage in a number of tobacco prevention activities right where people live, work, play, and worship, including: • direct counseling for prevention and to help people quit, • youth tobacco education programs, • interventions for special populations, • worksite programs, and • training for health professionals.

14. Helping Smokers Quit (Cessation): • A comprehensive tobacco control program should not only encourage smokers to quit but also help them do it. In fact, most smokers want to quit but have a very difficult time because nicotine is so powerfully addictive. • To help these smokers, cessation products and services should be made more readily available and more affordable. • Moreover, treatment programs are most effective when they utilize multiple interventions, including pharmacological treatments, clinician provided social support, and skills training.

15. Helping Smokers Quit (Cessation) (cont.): • Cessation services can be provided through primary health care providers, schools, government agencies, community organizations, and telephone "quit lines.“ • Staff training and technical assistance should be a part of all programs to treat tobacco addiction; and following the cessation guidelines from the Agency for Health Care Policy and Research will increase the effectiveness of any cessation efforts in clinical settings.

16. School-Based Programs: • School-based programs offer a useful way to prevent and reduce tobacco use among kids, especially when based on the CDC’s Guidelines for School Health Programs to Prevent Tobacco Use and Addiction. • To operate most effectively, school-based programs must include curricula that have been shown to be effective, as well as tobacco-free policies, training for teachers, programs for parents, and cessation services.

17. School-Based Programs (cont.): • Students must learn not only the dangers of tobacco use but life skills, refusal skills, and media literacy in order to resist the influence of peers and tobacco marketers. • It is critical that the school programs be integrated with other community-based programs and with counter-marketing efforts.

18. Enforcement: • Rigorously enforcing laws prohibiting tobacco sales to youth and limiting exposure to secondhand smoke is an essential element of creating an environment conducive to reducing tobacco use. • These enforcement efforts should include penalties for violators, and compliance enhancing education.

19. Enforcement (cont.): • To increase tobacco control enforcement, funds must be provided to enforcement agencies to make sure other enforcement efforts are not compromised. • Other agencies and organizations should also be supported to provide related educational efforts to raise awareness of the laws and their enforcement and to promote compliance.

20. Monitoring and Evaluation: • Every element of a comprehensive tobacco control program should be rigorously evaluated throughout its existence. • Careful monitoring and evaluation methods should be built-into the programs to provide the data necessary for continual improvement.

21. Monitoring and Evaluation (cont.): • Process measures should be developed to monitor the activities conducted under the program from the outside, as well, in order to block the misuse of funds and promote their most efficient and effective use. • Regular measurements of key outcomes should also be conducted to assess progress and further improve their performance.

22. Related Policy Efforts: • Additional policy initiatives have been proven effective in reducing tobacco use -- especially as part of a comprehensive strategy. • These policies include: • increases in cigarette excise taxes, • restrictions on tobacco marketing to kids, • increased penalties for selling tobacco to kids, • new restrictions on environmental tobacco smoke in public places.

23. GUIDING PRINCIPLES Past experience with tobacco control efforts indicates that five principles should guide the development of a successful state program to prevent and reduce tobacco use: • 1. It must be comprehensive. Stopgap or partial measures will meet with only partial success. Elements work most effectively when they are combined in complementary fashion.

24. GUIDING PRINCIPLES (cont.) • 2. It must be well funded. • Unless properly financed, tobacco prevention will have little effect against the marketing efforts of the tobacco industry (over $8 billion each year). • CDC has issued funding guidelines for state tobacco control programs, which can serve as a basis for planning.

25. GUIDING PRINCIPLES (cont.) • 3. It must be sustained over a long period of time. • While short-term attitudinal changes can occur relatively early, it will take years to achieve the significant behavioral and cultural changes necessary to reduce tobacco use substantially and maintain low levels. • If tobacco control programs are not sustained over many years, the chances for success will be diminished, and any early gains may be lost in subsequent years.

26. GUIDING PRINCIPLES (cont.) • 4. It must operate free and clear of political and tobacco industry influence. • History warns us that the tobacco industry will employ every manner of tactics to divert money from tobacco prevention and to interfere with any tobacco prevention efforts that are undertaken. • To avoid this tobacco industry sabotage, new tobacco control programs must be set up to be independent of these influences and insulated from them.

27. GUIDING PRINCIPLES (cont.) • 5. It must address high-risk and diverse populations. • The needs of special populations can and must be taken into account in designing and disseminating the various elements of the tobacco control program (e.g. youth, and women).

28. Guidelines for Individual Smoking Cessation

29. Introduction • There is good evidence that even brief advice from health professionals has a significant effect on smoking cessation rates. A supportive, ongoing relationship with a health professional is often an essential precursor to successful quitting. • Success in quitting smoking depends less on any specific type of intervention than on delivering personalized empathic smoking cessation advice to smokers, and repeating it in different forms from several sources over a long period. • Smoking cessation is a dynamic process that occurs over time rather than a single event. Smokers cycle through the stages of contemplation, quitting and relapse an average of three to four times before achieving permanent success.

30. Tobacco dependence is a chronic condition that often requires repeated intervention. However, effective treatments exist that can produce long-term abstinence. • These guidelines are designed for smoking cessation providers to assist all clients with smoking cessation.

31. Promoting Smoking Cessation • THE FIVE A’S: ASK ASSESS ADVISE ASSIST ARRANGE

32. ASK

34. ASSESS

37. ADVISE

41. ASSIST

48. ARRANGE

50. Smoking Addiction Calculator • The Fagerström test is a standard questionnaire that is used to determine if a smoker is addicted to nicotine. • There are several versions of the Fagerström test. The one we will use has 6 multiple-choice questions. Each of the multiple-choice responses has a point score. • After the person has answered all the questions, you need to add all points from the individual questions; this should give an integer between 0 and 10. • The person is then probably strongly addicted if the total score is 8 or more; addicted if the score is 6 or 7; mildly addicted if the score is 3, 4, or 5; and not addicted if the score is 2 or less.